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-8- <br />Certification: <br />As an authorized representative of the applicant, I hereby certify that the operation described has met the minimum <br />requirements of the following terms and conditions: <br />1. To the best of my knowledge, all significant, valuable and permanent man -made structures) inexistence at the time <br />this application is filed, and located within 200 feet ofthe proposed affected area have been identified in this application <br />(Section 34- 32.5- 115(4xe), C.R.S.). <br />2. No mining operation will be located on lands where such operations are prohibited by law <br />(Section 34- 32.5- 115(4)(f), C.R.S.; <br />3. As the applicant/operator, I do not have any extraction/exploration operations in the State ofColorado currently in <br />violation of the provisions of the Colorado Land Reclamation Act for the Extraction of Construction Materials <br />(Section 34- 32.5 -120, C.R.S.) as determined through a Board finding. <br />4. I understand that statements in the application are being made under penalty of perjury and that false statements <br />made herein are punishable as a Class 1 misdemeanor pursuant to Section 18 -8 -503, C.R.S. <br />This form has been approved by the Mined Land Reclamation Board pursuant to section 34- 32.5-112,C.R.S, of the Colorado Land <br />Reclamation Ad for the Extraction of Construction Materials. Any alteration or modrkadon of this form shall result in voldfng any <br />permit issued on the altered or modified form and subject the operator to cease and desist orders and civil penalties for opFradng <br />without a permit pursuant to section 332.5 -123, CRS <br />Signed and dated this day of ,//T i / ., Z;/ <br />John DeWitt / Lincoln County <br />Applicant/Operator or Company Name <br />Signed: _' `',` j�� l A' ' <br />d <br />Title: Land Use Administrator <br />State of <br />� <br />/ ) ss. <br />County of )tom � (�� ''� <br />If Corporation Attest (Seal) <br />110 <br />Corporate Secretary or Equivalent <br />Town/City /County Clerk <br />The foregoin rostrum nt was acknowledged before me this day of <br />?>. by Ch n iiLi I ` as oCi 1 nu: U& cld at'h Sw� � of vL <br />C�fLC <br />MINDY SCHIFFERNS Notary Public v <br />NOTARY PUBLIC <br />STATE OF COLORADO <br />NOTARY ID # 20134026866 My Commission expires: <br />MY COMMISSION EXPIRES APRIL 30, 2017 <br />SIGNATURES MUST BE IN BLUE INK <br />You must post sufficient Notices at the location of the proposed mine site to clearly identify the site as the location of a <br />